Original Article Application of Omaha System-Based Extended Care in Children with Severe Viral Encephalitis and Limb Hypofunction

Int J Clin Exp Med 2020;13(6):4282-4290 www.ijcem.com /ISSN:1940-5901/IJCEM0109202

Original Article Application of Omaha system-based extended care in children with severe viral encephalitis and limb hypofunction

Lili Sun1*, Demiao Yang2*, Sisi Shao3, Li Zhang2, Lili Kong4

1Department of Otorhinolaryngology, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China; 2Supply Room, Departments of 3Ophthalmology, 4Pediatrics, Shandong Zaozhuang Maternity and Child Health Care Hospital, Zaozhuang, Shandong Province, China. *Equal contributors and co-first authors. Received February 14, 2020; Accepted March 18, 2020; Epub June 15, 2020; Published June 30, 2020

Abstract: Objective: To explore the effect of Omaha system-based extended care in children with severe viral encephalitis (SVE) complicated with limb hypofunction. Methods: In this prospective study, 82 children with SVE complicated with limb hypofunction were selected and divided into two groups according to a random number table method: Omaha group (n=43, Omaha system-based extended care) and control group (n=39, routine extended care). The following indicators between the two groups were compared, including total nursing effectiveness, disability rate, recovery time of limb disorders, nursing satisfaction, Fugl-Meyer assessment (FMA) scores at hospital discharge (before nursing), 1 month and 3 months after hospital discharge (after nursing), and Pediatric Quality of Life Inventory (PedsQLTM 4.0) Generic Core Scale scores. Results: Children in the Omaha group had significantly higher nursing effectiveness compared with the control group (88.37% vs. 69.23%, P<0.05), lower disability rate (4.65% vs. 20.51%, P<0.05), shorter recovery time of limb disorders (11.46±2.78 d vs. 16.33±3.87 d, P<0.0001), and higher item scores and total scores of nursing satisfaction (service attitude, professional skills, health education, psychological counseling, and case management) (all P<0.0001). FMA scores in the two groups at 1 month and 3 months after nursing were increased compared with those before hospital discharge (all P<0.05), and FMA scores at all stages after nursing in the Omaha group were better than those in the control group (all P<0.01). Physiology, emotion, society, role and total scores of PedsQLTM 4.0 in the two groups were increased at 1 month and 3 months after nursing (all P<0.05), and each score at all stages after nursing in the Omaha group was higher than that in the control group (all P<0.05). Conclusion: Omaha system-based extended care can improve the motor function and quality of life of children with SVE complicated with limb hypofunction, effectively control the disability rate, and increase nursing satisfaction of children’s families; all of which are worthwhile to popularize and apply.

Keywords: Omaha system, extended care, severe viral encephalitis, limb function, quality of life

Introduction ally carried out within the hospital, and routine in-hospital care is given during the treatment. Severe viral encephalitis (SVE) is a central ner- However, the critical period for disease recov- vous system infectious disease caused by ery is 1-3 months after hospital discharge. enterovirus, herpes simplex virus and other Therefore, it is vital to treat patients with timely common infectious viruses [1]. When SVE and effective extended care when the care is occurs in children, pathological changes are transferred from the hospital to the home [3]. manifested as brain parenchyma necrosis, malacia or hemorrhage, which further triggers The Omaha system is a simplified standardi- obstacles to limb movement, language function zed nursing language system, which has been weakening, secondary epilepsy and other developed and improved since it was estab- sequelae; severe SVE can lead to mental retar- lished in the United States in 1975, and has dation, acroparalysis etc., with a disability rate been recognized and proved by many service as high as 20% [2]. The treatment of SVE is usu- institutions in many countries for its scientific- Omaha system-based extended care in SVE combined with limb hypofunction ness, effectiveness and applicability [4]. In besides SVE; children had congenital disease addition to clinical nursing, the areas of appli- or other chronic progressive diseases. cation after its introduction in China include education, scientific research and others. At Methods present, the Omaha system is mostly used for the nursing of patients with chronic diseases or Children in the control group were given medi- community patients in clinical practice, while it cation guidance and precautions at hospital is seldom used for the nursing of pediatric dis- discharge and received routine extended care eases. Previous study has found that when the after hospital discharge; regular telephone fol- Omaha system is applied to diseases that low-up began at 1 week after hospital discharge require extended care, it can improve the over- to follow the current physical symptoms, reha- all nursing for patients and their quality of life bilitation status, diet and daily activities of chil- [5]. Although the survival rate of children with dren, and health guidance was given and SVE increases with the development of the recorded according to the specific conditions. level of intensive care medicine in China, it is Home visits were arranged and recorded at 1 still a long way to recover from sequelae after month after hospital discharge. treatment; this is an urgent and difficult problem to be solved in clinical nursing of this dis- Children in the Omaha group received Omaha ease [6]. In view of the particular stages of the system-based extended care in addition to care recovery of children with SVE, Omaha system- received in the control group. Details were as based extended care was applied to 3-month follows. out-of-hospital nursing for children in this study, Establishment of Omaha nursing team to explore the effect of this nursing model on prognostic recovery in SVE children with motor The team members included a chief physician, dysfunction. a head nurse, a nursing postgraduate student, Materials and methods a psychotherapist, a physical therapist, and several clinical nurses. All team members had General data more than 5 years of work experience in pediatrics except the nursing postgraduate. All team In this prospective study, 82 children with SVE members were trained and passed relevant complicated with limb hypofunction who were examinations. The training methods included admitted to Shandong Zaozhuang Maternity expert instruction and online video courses. and Child Health Care Hospital from June 2017 to May 2019 were selected and divided into Nursing problems classification two groups according to a random number table method: Omaha group (n=43, Omaha At 3 d before hospital discharge, children were system-based extended care) and control assessed by reference to environment, social group (n=39, routine extended care). This study psychology, physiology, and health behavior of was approved by the Ethics Committee of the Omaha system, including a total of 42 guid- Shandong Zaozhuang Maternity and Child ance survey questions; according to the specif- Health Care Hospital. ic symptoms of children after assessment, the nursing problems were determined and the Inclusive criteria: Diagnostic criteria for SVE in intervention direction was formulated [8]. For Pediatrics Ninth Edition published by the children facing multiple nursing problems at People’s Medical Publishing House were met the same time, Maslow’s hierarchy of needs [7]; children were accompanied by limb hypo- was adopted according to the individual needs function, with the Fugl-Meyer assessment and symptoms of children, to prioritize each (FMA) score of <50; children were 2-11 years nursing problem before intervention. old; children’s families had normal communication skills and no dyslexia; children’s families Development of intervention measures agreed and signed the informed consent form. Based on the nursing process of the Omaha Exclusive criteria: Children were complicated system, the above nursing problems were sub- with other central nervous system diseases classified into 76 intervention directions in

4283 Int J Clin Exp Med 2020;13(6):4282-4290 Omaha system-based extended care in SVE combined with limb hypofunction terms of four nursing practices: health educa- At the 1st month after hospital discharge, a tion guidance and consultation, treatment pro- home visit was performed to provide familial cedures, case management and monitoring [9]. guidance face to face. The results of measured Then intervention directions were summarized items within 1 month were assessed, such as and adjusted to formulate an extended care the scores of motor function and quality of life. plan suitable for SVE children in our hospital. The feasibility of current nursing pattern, Details were as follows. whether to continue the plan, and whether previous nursing problems had been solved were On the day of hospital discharge, health records weighed. The nursing effect at this stage was of all children were completed, including the evaluated. If other nursing problems appeared, time of first onset, the time of first diagnosis, a corresponding intervention strategy was for- prodromal symptoms, all inspection reports mulated according to the children’s symptoms. and nursing measures. Discharge instruction was then performed through multimedia, and At the 2nd month after hospital discharge, nurs- the video presentation content included rou- ing continued. Telephone follow-up or home tine symptom identification and management, visit was carried out to record the current health medication guidance, and precautions of diet, status of children, track nursing implementa- exercise and rest. The families were informed tion of children’s families and determine nurs- to record the health status of children on time ing progress. at home for doctor’s review at the subsequent visit. At the 3rd month after hospital discharge, the above nursing process were continued, and the The physical therapist instructed the families to final nursing effect was assessed. massage children’s joints by slow push and pull from top to bottom and guided the children to Outcome measurements and evaluation crite- slowly stretch their limbs. The families were ria guided to massage children’s Baihui, Fengchi and Zusanli points for smooth blood circulation The scale evaluators in the team collected each of limbs and prevention of contracture of joints. indicator by questioning the study subjects Meanwhile, the children were guided to carry before hospital discharge or at 1 month and 3 out joint movement of the injured limb; the chil- months after hospital discharge. The collection dren with level I movement disturbance per- was carried out strictly according to the specific formed passive motion; the children with level II indicator evaluation period. The collection time and III performed active movement with assis- of each child was not less than 20 min, and the tant passive motion; the children with level IV questionnaire was collected on site. Forty-three performed impedance movement. Children copies of each questionnaire were collected were massaged 5-8 times/d and exercised 4-6 from 43 children in the Omaha group, without times/d. Each massage and exercise were no anyone dropping out nor lost to follow-up. less than 15 min and no more than 30 min. Limb motor function scoring At the 1st week after hospital discharge, intervention directions were formulated based on Limb motor function was evaluated by using children’s main nursing problems and symp- the FMA scale, with a maximum score of 100, toms. The physical therapist made the rehabili- including 50 items (33 items for upper limb tation program, and the psychotherapist car- function, and 17 items for lower limb function) ried out psychological nursing in real time. each item having 2 scores [10]. The total score Details were shown in Table 1. was the sum of each item score. A FMA score of less than 50 indicated severe movement dis- At the 3rd week after hospital discharge, a fur- turbance (level I); a score of 50-84 indicated ther consultation in the clinic was arranged for apparent movement disturbance (level II); a the children to carry out routine child health score of 85-95 indicated moderately apparent care and record their growth and development. movement disturbance (level III); and a score of A physical examination involving the nerve was 96-99 indicated mild movement disturbance performed by the chief physician. (level IV).

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Table 1. Main nursing problems and intervention directions of children in the Omaha group Classification Nursing problems Main symptoms and signs Intervention directions Environment Sanitary condition of 1. Poor and humid dwelling environment with dead air 1. Keeping the dwelling environment clean and tidy, regular indoor air ventilation, residence 2. Interior structure and decoration with potential safety hazards and regular sun exposure 2. Removing the obstacles to ensure no potential safety hazards indoors and around Physiology Nerve-muscle-skeleton 1. Weak muscle strength, joint movement disorder, and paralysis of one lower limb 1. Regular massage, and keeping limb joint movement Social psychology 1. Mental status 1. Emotional instability, easy to be agitated, anxiety, and obvious fear 1. Psychological nursing 2. Social activity 2. Delirium, and unconsciousness 2. Further consultation as requested, and symptomatic treatment 3. No interests and hobbies, un-sensible social activities, and limited role function 3. Encouragement and support from the families, and training coping skills Health behavior 1. Health education 1. Lack of awareness of the disease, and failed to follow the doctor’s advice 1. Continuous education of health knowledge, and follow up and return visit 2. Daily habits 2. Sleep insufficiency 2. Keeping in quiet and comfortable status 3. Eating disorder, and insufficiency of nutrient intake 3. Strengthening diet management

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Statistical analysis Table_ 2. Comparison of general data between the two groups ( x ± sd, n/%) All data were analyzed by SPSS Control group Omaha group χ2/t P 21.0 professional statistical soft- (n=39) (n=43) ware. The measurement data Gender 0.084 0.773 were shown_ as mean ± standard Male 23 (58.97) 24 (55.81) deviation ( x ± sd) and analyzed Female 16 (41.03) 19 (44.19) by independent-samples t test Age (year) 7.7±2.1 7.8±2.6 0.190 0.850 (expressed as t). The enumera- Course of disease (day) 6.51±1.77 6.23±1.09 0.852 0.397 tion data were shown as n/% and FMA scores (score) 41.45±7.23 41.98±6.34 0.354 0.724 analyzed by chi-square test and Fisher’s exact test (expressed as Swallowing dysfunction 6 (15.38) 8 (18.60) 0.150 0.670 χ2). P<0.05 indicated a significant Note: FMA, Fugl-Meyer assessment. difference.

Nursing effectiveness, disability rate and re- Results covery time of limb disorders Comparison of general data Nursing effectiveness referred to the FMA scores that rose from level I to level II and There were no differences in general data above. Disability rate included the incidences between the two groups (all P>0.05, Table 2). of mental retardation, paralysis of one side of the body and secondary epilepsy. Comparison of nursing effectiveness, disability rate and recovery time of limb disorders Quality of life scoring Children in the Omaha group had significantly Pediatric Quality of Life Inventory (PedsQLTM higher nursing effectiveness (88.37% vs. 4.0) Generic Core Scale - Chinese Version was 2 used to evaluate the quality of life [11]. This 69.23%, χ =4.560, P=0.033), lower disability 2 scale, developed by the research team was led rate (4.65% vs. 20.51%, χ =4.805, P=0.028), by professor Vami J.W of the California Chil- and shorter recovery time of limb disorders dren’s Hospital and Health Center in San Diego, (P<0.0001, Table 3 and Figure 1) compared USA; and is suitable for systematic measure- with the control group. ment of health-related quality of life in children aged 2 to 18. In China it is often used to evalu- Comparison of FMA scores before nursing and ate the quality of life of children with various at different stages after nursing acute and chronic diseases. Cronbach’s α was 0.74-0.82. This scale included four dimensions The FMA scores at 1 month and 3 months after of physiology, emotion, society, role and overall nursing were higher than those before nursing situation and was filled in by children’s families. (all P<0.05). The FMA scores at each stage Each dimension scored 0-100, and the total after nursing in the Omaha group were signifi- score was the mean value of each dimension cantly higher than those in the control group (all score. The score was proportional to the quality P<0.01, Table 4). of life. Comparison of PedsQLTM 4.0 scores before Nursing satisfaction of the families nursing and at different stages after nursing The hospital-made nursing satisfaction evalua- Physiology, emotion, society, role and total tion form (reliability: 0.783, validity: 0.861) was TM used, including 5 aspects: service attitude, scores of PedsQL 4.0 significantly increased professional skill, health education, psycholog- at 1 month and 3 months after nursing in the ical counseling and case management, with a two groups compared with those before nurs- maximum score of 100. This form included 20 ing (all P<0.05), and each item score at each questions, with a score of 1-5 for each ques- stage after nursing in the Omaha group was sig- tion. The score was proportional to the degree nificantly higher than that in the control group of satisfaction. (all P<0.05, Table 5).

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Table 3. Comparison of nursing effectiveness, disability rate and recovery time of limb disorders Nursing Disability rate (n, %) Recovery time of Group effectiveness (n, %) Epilepsy Mental retardation Paralysis Total limb disorders (days) Control (n=39) 27 (69.23) 4 (10.26) 3 (7.69) 1 (2.56) 8 (20.51) 16.33±3.87 Omaha (n=43) 38 (88.37) 2 (4.65) 0 (0.00) 0 (0.00) 2 (4.65) 11.46±2.78 χ2/t 4.560 0.948 3.433 1.116 4.805 6.509 P 0.033 0.330 0.064 0.291 0.028 0.000

Discussion

For SVE, there are no particular antiviral therapeutic measures currently. The main symptomatic treatments and supportive treatments can temporarily alleviate the dete- rioration of children’s condition, but the high incidences of sequelae severely affect the healthy growth of children. Therefore, continuous nursing after hospital discharge is Figure 1. Comparison of nursing effectiveness, disability rate and recovery important for the rehabilita- time of limb disorders. A. Comparison of nursing effectiveness between two tion and quality of life of the groups. B. Comparison of disability rates between two groups. C. Compari- children [12, 13]. Extended son of recovery time of limb disorders between two groups. Compared with care can give children compre- * **** the control group, P<0.05, P<0.0001. hensive and coordinated individual nursing in different health care sites through a Table 4. Comparison of FMA_ scores before nursing and at different stages after nursing ( x ± sd) series of program designs [14]. However, the routine cur- 1 month after 3 months after Group Before nursing rent out-of-hospital extended nursing nursing care in China is faced with * * Control (n=39) 41.45±7.23 59.93±6.77 65.09±7.12 many problems, such as short- Omaha (n=43) 41.98±6.34 73.21±8.18# 79.44±8.40# age of nursing manpower, sin- t 0.354 7.962 8.300 gle nursing content, long P 0.724 0.001 0.001 course of nursing, and low Note: Compared with before nursing in control group, *P<0.05; compared with compliance of children and before nursing in Omaha group, #P<0.05. FMA, Fugl-Meyer assessment. their families, causing unsat- isfactory nursing effects.

Comparison of nursing satisfaction scores of Previous studies have found that by the appli- families cation of the Omaha system in clinical nursing, nursing problems in terms of children’s family Each item score and total scores of nursing sat- environment, social psychology, daily health isfaction of families in the Omaha group were behavior and others can be identified, and then significantly higher than those in the control intervention measures can be formulated [15, group (all P<0.0001), manifesting in service 16]. The advantage of the Omaha system is attitude (18.43±2.57 vs. 14.33±2.16), profes- that it has a complete system process: problem sional skill (18.25±2.33 vs. 15.32±2.78), classification, practice intervention, and effec- health education (17.64±2.18 vs. 14.98±3.13), tiveness evaluation. Moreover, studies have psychological counseling (17.78±2.75 vs. proved that a retrospective analysis on the 13.71±2.67), case management (18.56±2.06 applicability of problem classification, the perti- vs. 13.23±3.18), and total score (90.12±6.42 nence of practical measures and the rationality vs. 71.76±5.02, Figure 2). of effectiveness evaluation in the nursing cases

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TM Table_ 5. Comparison of PedsQL 4.0 scores before nursing and at different stages after nursing ( x ± sd) Item Time Control group (n=39) Omaha group (n=43) t P Physiology Before nursing 44.53±4.61 44.72±5.03 0.178 0.859 At 1 month after nursing 46.21±4.12a 49.32±6.36a 2.651 0.010 At 3 months after nursing 49.47±5.68a,b 54.27±7.01a,b 3.385 0.001 Emotion Before nursing 58.23±5.06 57.74±6.74 0.369 0.713 At 1 month after nursing 60.37±5.85a 63.56±6.39a 2.350 0.021 At 3 months after nursing 63.89±6.13a,b 67.72±6.73a,b 2.684 0.009 Society Before nursing 55.63±5.17 56.13±5.88 0.407 0.685 At 1 month after nursing 57.98±5.07a 60.93±5.62a 2.486 0.015 At 3 months after nursing 62.05±7.64a,b 66.23±8.30a,b 2.365 0.020 Role Before nursing 39.88±4.22 38.13±4.09 1.906 0.060 At 1 month after nursing 44.25±5.08a 47.34±4.97a 2.782 0.007 At 3 months after nursing 49.23±5.52a,b 55.27±6.71a,b 4.425 0.000 Total score Before nursing 48.99±5.01 50.10±5.33 0.969 0.336 At 1 month after nursing 52.71±6.03a 56.42±6.77a 2.610 0.011 At 3 months after nursing 58.19±7.21a,b 63.45±8.02a,b 3.111 0.003 Note: Compared with before nursing within the group, aP<0.05; compared with at 1 month after nursing within the group, bP<0.05. PedsQLTM 4.0: Pediatric Quality of Life Inventory Generic Core Scale.

obtained by analyzing their problems in physiology, environment and health behavior, and the corresponding intervention measures were formulated based on the intervention direction. Members in the nursing team performed their own duties; the psychotherapist provided professional psychological counseling, and the physical therapist was respon- sible for exercise rehabilitation guidance [19]. During the process, the nursing effect on children at different nursing stages was evaluated and adjusted, and the periodical Figure 2. Comparison of family nursing satisfaction scores. Compared with **** effectiveness evaluation was the control group, P<0.0001. the best evaluation of the children’s improvement and nurs- and measures that are sorted out by the Omaha ing problems, thus thoroughly achieving the electronic software provides guidance for clini- seamless extension of nursing from the hospi- cal nursing [17, 18]. Compared with North tal to home for children [20]. Throughout the American nursing diagnosis, the Omaha sys- nursing process, a harmonious doctor-nurse- tem is more suitable for out-of-hospital case patient interactive relationship was built; punc- management and home visits in China. Th- tual telephone communication with high quality erefore, it was applied in the extended care of and regular home visits strengthened the children with SVE in this study. sense of trust of families and ensured an easy and pleasant nursing process. In addition, the In this study, a detailed and objective current service concept of extended care enabled the condition of children in the Omaha group was sustainable implementation of nursing and

4288 Int J Clin Exp Med 2020;13(6):4282-4290 Omaha system-based extended care in SVE combined with limb hypofunction strengthened the compliance of children and shortcoming of this study was a small sample their families to the rehabilitation treatment of size. In future study, the sample size should be diseases; punctual further consultation and increased. In addition, it would be more com- regular examination promoted the recovery of prehensive if the Omaha system was used to illness and motor dysfunction. Studies found evaluate the recovery effects of children. that when the vital signs of SVE children were stable, massaging the children at the critical In summary, Omaha system-based extended period of disease recovery after discharge care can improve the motor function and quali- could reduce the incidences of joint stiffness ty of life of SVE children complicated with limb and atrophy, and timely joint movement could hypofunction, effectively control the disability prevent any secondary damage that was rate, and increase nursing satisfaction of chil- caused by secondary limb disorders such as dren’s families, which is worthwhile to popular- foot drop [21-23]. In this study, the families of ize and apply. children in the Omaha group were instructed to Disclosure of conflict of interest massage their children from the day of hospital discharge, and the corresponding joint move- None. ment of the affected limb was performed according to children’s level of motor dysfunc- Address correspondence to: Lili Kong, Department tion. Punctual telephone follow-up and face-to- of Pediatrics, Shandong Zaozhuang Maternity and face instruction at home visits from 1 month to Child Health Care Hospital, Fuyuan Third Road, 3 months after hospital discharge ensured the Xuecheng District, Zaozhuang 277100, Shandong extensibility and continuous effectiveness of Province, China. Tel: +86-0632-3187633; E-mail: nursing intervention. [email protected]

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